A 3-year-old male presented for an elective circumcision. He was an ex-32-week preemie with reactive airways and a recent URI requiring nebulized albuterol. The URI resolved 3 weeks ago, and he took a course of antibiotics. PO midazolam was given in pre-op holding area for anxiolysis, and he was calm on arrival to OR. Mask induction was performed, initially 70/30 N2O/O2, then sevoflurane 8%. A rotating dental resident held the face mask. I noted obstruction, instructed rotator to perform jaw thrust and a second resident to turn the APL valve to 5 cm H2O. The EtCO2 tracing went flat, I took over bag mask ventilation. I was able to give 2-3 small breaths with APL at 30 cm H2O with FiO2 100%, but the patient then vomited abaout 5 mL milky fluid. I instructed the resident to give 1 mL...
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October 2023
Anesthesia Incident Reporting System Case 2023-10: Baby, It's Cold Outside
ASA Monitor October 2023, Vol. 87, 1–5.
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Anesthesia Incident Reporting System Case 2023-10: Baby, It's Cold Outside. ASA Monitor 2023; 87:1–5 doi: https://doi.org/10.1097/01.ASM.0000989848.74927.15
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